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Thursday, February 01, 2007

Is Health Care for the Poor Better Abroad?

The National Center's David Hogberg has noticed a theme among left-of-center polemicists, who, when writing on health care, seem to be assuming that the poor get better health care when they live in nations with government-run systems. But is this assumption based on solid evidence? David examines the question:

I've noticed that a number of folks on the left argue that universal health care in other nations results in more equal treatment for the poor. In a conversation being held over at Cato Unbound on the subject of how well the poor are served by various health care systems, New Republic Senior Editor Jonathan Cohn seems to argue that government systems better serve the poor.

In that essay, Arnold, you graciously admitted you had no easy answer for what will happen to the working poor and the chronically ill - and suggested that might be a proper function for government. I appreciate the concession and take your word seriously. I'll simply caution you that we've been trying to take that very approach for the last 40 years or so. And it hasn't worked too well. The reason? Programs exclusively for poor people tend to be poor (because they lack powerful political constituencies). I guess you could also say that programs exclusively for the chronically ill tend to be chronically ill themselves. If you don't know what I mean, I suggest you examine more closely the very checkered history of state high-risk pools - a supposed innovation to help the chronically ill that has a decidedly checkered record.

Now, conservatives typically respond to this explanation by asking why I have faith in government to take care of everybody's health care if it can't even take care of some people's health care. My answer is that they do it, and do it well, abroad.

The notion that government-run systems are better for the poor is also present in this column by University of Colorado law professor Paul Campos:

In one sense, the U.S. clearly does have the best health care in the world: If you're rich, America is a great place to get sick. We do, in fact, have the best doctors and hospitals in the world. So why do we have below-average health, as compared to other developed nations?

The answer is simple: because, if you're poor, America is a much worse place to get sick than any of dozens of other countries that, despite being far less wealthy than the U.S., find a way to provide good medical care for all their residents.

But do the poor in other countries really receive good medical care? It doesn't seem that way. Consider this paragraph from the free-market Fraser Institute's annual report on waiting lists in Canada:

Finally, the promise of the Canadian health care system is not being realized. On the contrary, a profusion of research reveals that cardiovascular surgery queues are routinely jumped by the famous and politically-connected, that suburban and rural residents confront barriers to access not encountered by their urban counterparts, and that low-income Canadians have less access to specialists, particularly cardiovascular ones, are less likely to utilize diagnostic imaging, and have lower cardiovascular and cancer survival rates than their higher-income neighbours.

You can see all of the research the Fraser Institute points to on page 9 of the report, but let me cite just one study. In the New England Journal of Medicine, a number of researchers examined the effect of socioeconomic status on access to cardiac procedures in Ontario, Canada. Their study found that going from the lowest income neighborhood to the highest increased by 23% the use of cardiac angiography (a heart test) and decreased by 45% the waiting time to get one. The study ended with this grim conclusion:

In conclusion, despite universal health insurance coverage, Ontario residents living in lower-income areas have reduced access to invasive procedures, as compared with residents of wealthier neighborhoods, and have sharply higher mortality one year after hospitalization for acute myocardial infarction. The causes of these socioeconomic disparities in access and outcome remain obscure, but their persistence poses a clear challenge to the egalitarian principles of Canada's publicly funded health care system.

It isn't much better in Great Britain. The "Acheson Report" has found that "Although average mortality has fallen over the past 50 years, unacceptable inequalities in health persist. For many measures of health, inequalities have either remained the same or have widened in recent decades." The report noted that, the "weight of scientific evidence supports a socioeconomic explanation of health inequalities."

While the report further noted that income inequality had widened in recent years, income had risen across all groups. So, if income increased for all groups, why did inequalities in health stay the same or worsen? That's beyond my capabilities to answer. What is does suggest is that the universal health care of Britain doesn't seem to be doing much to reduce health inequalities.

Here's another comparison. Go to Saga's Good Hospital Guide for British hospitals. Compare the ones in Inner London, which tend to be in wealthier areas, to the ones in Outer London, which tend to be in poorer areas. You'll notice that in general, the ones in Inner London have more doctors and nurses per bed, shorter wait times for MRIs and hip replacements, and lower mortality ratios.

Thus, the health care inequities that occur in the U.S. also occur in other countries. I suspect that Cohn is correct that the reason Medicaid is poor is that it has a poor constituency-i.e., the poor do not participate in politics any where near the rate of the affluent. Yet the experience of Canada and Britain suggest that the problem also replicates itself in universal health care systems. Thus, any government system in a democracy is going to result in more resources going to affluent areas and less to poor ones-including health care systems.